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Aviation Safety Culture : Don’t shoot the piano player

Once again, in connection with the 2009 Air France AF447 Rio to Paris flight, there have been some lousy finger-pointing exercises. For some reason, each time a new possible clue or fact leaks from the ongoing analysis of the precious recovered black boxes, corporate aviation entities have been quick to suggest yet another sign of pilot error in the crash of AF447. Then, the ‘possible’ clue or cause associated with the crash is elevated to a factual statement by certain news media, enough to cause a stir among affected groups, such as airline pilots. The news then goes around full circle and lands on the lap of the initial news source, followed by denials or claims of misinterpretation. Such needless frenzy!

The alleged fact, for example, that the pilot-in command (P-I-C) was not in the cockpit at the time the AF447’s Airbus 330 fell out of the sky in the equatorial zone on its way across the Atlantic ocean to Paris, made immediate headlines. It’s the kind of sensational information that news headlines are made of, until superseded by corrective updates.

Airline pilots associations and unions have every right to be concerned about the knee-jerk attitude found in early press releases by aviation representatives.

Even though the root cause of major aviation accidents is nearly impossible to isolate, airline executives and the media are prompt to call for “pilot error”. Yet these same individuals know very well that aviation safety culture is at the centre of countless major aviation accidents. Aviation safety culture is not a person, real or corporate, on whom courts can lay liability for air disaster. Witness the French lower court’s ruling, last December, over the July 2000 supersonic Concorde crash at the Charles de Gaulle Airport in Paris. The court unwisely laid the blame squarely on an aircraft maintenance engineer and his supervisor, naturally, employed by Delta Airlines. See the Concorde saga earlier in this blog.

With the advent of jumbo jets in the 70s and after, a theoretical question was raised a few times, one showing the temporary disconnect between safety regulations and pilot-in-commands’ responsibilities: can the P-I-C of a departing Boeing 747, for example, be held accountable for all safety matters related to the planned flight or not? Who provides the load sheet to the P-I-C after the jumbo jet is fully loaded with fuel and payload, including number and distribution of passengers on board? Is the P-I-C expected to visually check that the list of contents of the jumbo jet shown on the load sheet is accurate?

The common sense answer is that the P-I-C of a large aircraft is entitled to rely on the work performed by well trained company ground crew prior to push-back from the gate. Check, for instance, the number of times provisions of the Canadian Aviation Regulations start by stating: “The pilot-in-command of an aircraft shall ensure that...?” To “ensure” is just about the best these pilots can do. In that verb resides the duty of “due diligence” pilots are held to, as in many regulated professions . Pilots of large aircraft cannot personally guarantee success at all stages of flight and need to rely on other aviation professionals to fly aircraft from A to B safely.

As we have seen with the Gimli Glider’ case back in early 80s, the P-I-C of an Air Canada Boeing 767, had to make a quick mental calculation about the fuel uplift provided to him in liters in order to convert liters to pounds of fuel. The captain erred, simple as that. But the litre to pound conversion, as simple as it may appear from the comfort of our home or offices is something different when the pilot is busy enough with pre-departure checks and signing documents submitted by ground crew. As luck would have it in the ‘Gimli Glider’ case, an important fuel gauge in the cockpit was tagged as unserviceable. As a result, the Boeing 767 ran out of fuel about mid-way through the flight. However, it was later agreed, after the heroic engine-out landing at Gimli aerodrome near Winnipeg with no casualties and relatively little damage to the airliner (compared to what it could have been), that the relevant operating manual needed to be reworded to better account for the co-existence of both measuring systems in civil aviation: the imperial one and the metric one. Do such improvements to flight operating manuals support the theory of pilot error as the central cause of an aviation accident? Let’s be real.

And this case is one among so many other aviation mishaps where pilot error was excusively and initially on many persons’ mind.

Remember the more recent Swissair 111 horrific crash off Canada’s East Coast, near Peggy’s Cove? Why did it take the crew nearly 20 minutes to go through the checklist regarding smoke in the cockpit at a point in flight where every minute mattered to get the doomed jumbo jet down safely on the ground at Halifax Int’l (as it was then called)? Was the pilot expected to breach company policy and chuck the emergency checklist away?

It goes both ways, doesn’t it? In the Swissair 111 case, airline safety culture was so tight it probably gave pilots less personal initiative in emergency situations. Who knows for sure, though? However, the common theme and repeated lesson are that airlines and pilots need to work closer together at all practical times on safety culture, in a way that both management and pilots are ad idem on safety issues. Any airline at odds with the pilots’ union, for instance, over the expiry of the collective agreement and that consequently allows mutual communications over safety matters to fall by the way side, is not operating at peak safety level. Airline pilots are not mercenaries. A friendly employment environment is naturally conducive to pilots staying more focused during flight duty time. This is trite observation and yet in the real world, things do not always support it.

So, whatever happened, in a general way, to AF447 on its way to Paris between Brazil and Senegal, might soon be known as the contents of the cockpit voice recorder and flight data recorder are likely to be made public sooner than originally stated, as a result of pressure from stakeholders in the deadly crash, and from the public at large who has the right to know what went wrong. What purposes would prolonged secrecy really serve by withholding the contents of the black boxes? Surely not certainty of accident cause, because there is no such thing as a single cause in any major aviation accident (repetition intended.)

To all concerned: please hold your fire after obtaining raw information from the black boxes. Think of AF447 and its doomed passengers and crew as part of a large system managed and operated by many skilled players, most of them safely on the ground when tragedy strikes on rare occasions. In truth, any rare occasion is still too much. Work is continuously underway to reach 100% safety in civil aviation.

For those who don’t already know: there is nothing basically wrong with the pilot-in-command of a large airliner taking a nap during the cruise stage of a long flight, while a back-up pilot fills in alongside the first officer during the captain’s needed break.

Now, to hear from experts on the civil aviation safety record, here is a link worth checking: Flightglobal Safety Review. Their take, as can be expected, is that there is plenty of room to improve aviation safety even though aviation remains statistically one of the safest modes of public transport. Flightglobal looks at civil aviation safety from a broad historical perspective. That alone puts their report on aviation safety a couple of notches above similar reports.